Case

76M pmh alcoholic cirrhosis, COPD presenting with altered mental status, vomiting, and diarrhea. Pt has been on a 3-day cocaine binge with increasing confusion and decreased oral intake. No fevers/chills, hematemesis.

Pt is hypotensive 80/40s despite 1 L. Pt is awake and alert but confused, aox0. Pt hypoglycemic to 45, received D50 with no improvement. K 2.8 but all other labs were normal. 

Pt was started on pressors but no significant improvement in BP.  The patient’s family stated said that the patient is in an out of hospitals for COPD and was recently discharged and has not been able to take his steroids.

The patient was treated with IV hydrocortisone for presumed adrenal crisis and admitted to MICU.  The patient’s mental status gradually improved after a few hours with resolving hypotension and was discharged the next day completely well.

Background

Adrenal glands produced mineralocorticoids, glucocorticoids, and androgens

Adrenal insufficiency affects 1-4/100,000 in the US, 80% from primary addison’s disease, other causes are trauma, drugs, infections, genetic disorders, sudden termination of prolonged glucocorticoid therapy, and pituitary disease (brain tumor/necrosis)

Adrenal insufficiency is extremely difficult to diagnosed in the ED, 44% of cases are diagnosed only after presenting in adrenal crisis

Stressors likely infection, surgery, trauma, emotional stress can exacerbate adrenal insufficiency

Presentation

Insufficiency: general dehydration, weakness, lethargy, AMS, delirium flank/back/abd pain, nausea, vomiting diarrhea, anorexia

Crisis: severe hypotension refractory to IV fluid and vasopressors

Diagnostic Studies

There are no great studies for adrenal insufficiency in the ED, random cortisol levels should not be drawn routinely, cortisol > 34 mcg/dL exclude adrenal crisis and < 15 is suggestive but this test is dependent on the patient’s corticosteroid binding globulin so free cortisol levels are very unreliable

Imaging in the ED is generally not necessary but if there are headaches suggestive of pituitary gland tumor or abdominal pain suggestive of secondary adrenal insufficiency, CTH and CTAP are options that can be used.

Treatment

If adrenal crisis is suspected, steroid should be given

Hydrocortisone 100 IV then 100 mg IV q 8h until acute crisis resolves, usually pt’s hypotension and clinical symptoms improves 1-2hrs after administration of hydrocortisone

50 mg for children 3-12 yo

25 mg IV for children < 3 yo

IVF up to 2-3 L

D5NS can be used as well for hypoglycemia, d50 for severe hypoglycemia

Vasopressors can be used but the patients are often unresponsive

Disposition

Admit to MICU for adrenal crisis

If patient is well appearing and just having weakness or fatigue, the patient can be discharged with followup with an endocrinologist/PMD who can do a normal serum cortisol level and ACTH stimulation tests as well as other extensive testing.

Steroid tapers for chronic steroid users I unfortunately there isn’t an optimal regimen verified by studies

For patients with short term glucocorticoid therapy (less than 3 weeks), you just stop and no taper needs to be given

For more chronic glucocorticoid therapy, it will depend on the dose the patient has been on, infection risk, duration of previous use, danger of underlying illness:

              Taper 5-10 mg/d every week from an initial dose > 40 mg prednisone or equivalent/day

              Taper 5 mg/d every week at prednisone doses 40-20 mg/d

              Taper 2.5 mg/d every two weeks at prednisone 20-10mg/d

              Taper 1 mg/d every 2 weeks at prednisone 10-5 mg/d

Generally we will only give 1-2 week course of medications from the ED, so make sure to do the calculations and give endocrine follow-up

Takeaways

For patients who are chronically on steroids often times for COPD, rheumatoid arthritis, crohn’s, etc. ask when the last time the patient had steroids; the patient might benefit from a steroid taper to prevent withdrawal.

Adrenal crisis is extremely rare and one should not wait for cortisol levels for a patient who is hypotensive and non-responsive to IVF/pressors. (often times, it’s just going to be that septic old patient that comes in with no clear history that’s unresponsive to pressors)

Prehospital Sedation

Alright, buckle up, everybody. Let’s talk sedation.

Specifically, we’re diving into prehospital sedation for procedures, namely intubation and cardioversion/pacing. Sedation options for the patient with excited delirium will be covered in a future email.

There have been LOTS of questions surrounding sedation strategies for intubation, and there seems to be a LOT of confusion with how to deal with these calls based on various OLMC recordings. So let’s clarify some points:

1.       EMS crews in NYC do NOT carry paralytics, and so intubations are technically not RSI, but rather medication-assisted intubation (MAI).

a.       There is one exception to this with FDNY’s specially trained rescue paramedics, who receive training in Rocuronium and Succinylcholine for very specific circumstances, but these cases will never come to our OLMC phone, so you’re better off ignoring it.

2.       Paramedics do not require OLMC approval to intubate, but they DO require OLMC approval for sedation medications in the pre/post-sedation period. For example, they do not need to call us to intubate an unresponsive patient in respiratory failure, but if that patient becomes agitated to the extent that they need sedation for the intubation, OLMC is required.

a.       This allows crews to intubate patients without calling first if the patient is truly in such extremis that they can’t resist the intubation procedure.

b.       If the patient DOES require sedation for intubation and the crew calls to request orders, I personally use this as an opportunity to (quickly) discuss the case with the crew. Does the patient really need intubation at all? Is NC/NRB sufficient? Would they tolerate CPAP? Is an NPA with BVM ventilation all they need until they get to the ED, or would they just get intubated on arrival anyway? Also recognize that quality bagging is extraordinarily difficult with a 2-person crew that is simultaneously carrying a patient down 6 flights of stairs and into the back of a soon-to-be-moving ambulance, which may be another reason to justify a more definitive airway. Often, if the patient is awake enough to need sedation, you can take a minute or two to ask some of these questions.

3.       EMS crews in NYC do NOT carry paralytics. Don’t ask them to give them.

4.       When discussing the medications used by paramedics for sedation, there are specific combinations of meds permitted as Medical Control Options. Please look closely at the attached pdf to see what meds and dosages are explicitly written, and begin to familiarize yourself with the options. Briefly, for intubation, they are:

a.       Diazepam, dosed before and after intubation, OR

b.       Midazolam, dosed before and after intubation, OR

c.       Etomidate before intubation, followed by a SINGLE dose of a benzodiazepine after intubation.

d.       That’s it. Try to keep those three options separate, as sometimes even crews will get wrapped up in the confusion and blend the choices together (eg, a call asking for Etomidate before intubation, Diazepam after intubation, and a SECOND dose of Diazepam “just in case” is a common OLMC request that inappropriately combines options A and C, but recognize that that’s a lot of sedation!).

e.       If needed, other medications such as Ketamine or Fentanyl can be used as Discretionary Orders (crews carry and are trained in those medications for EDP and Pain Management protocols, respectively; you are requesting an “off-label” use). I will often use this strategy for the hypotensive patient requiring intubation, as I personally don’t like benzos or Etomidate in those scenarios.

5.       EMS crews in NYC do NOT carry paralytics.

6.       MCOs for sedation for synchronized cardioversion or transcutaneous pacing are similar to those for intubation but utilize half-dose Etomidate. Check the pdf for specifics.

7.       Like discussed in the last email, be sure to practice good closed-loop communication when authorizing these medications, which means giving the name of the medication, the dose, and the route (these should all be IV/IO; if a crew wants to intubate, cardiovert, or pace, but they don’t have some sort of vascular access, you may want to discuss priorities with them). Have the crew repeat the order back to you! This prevents errors and should be standard patient care!

8.       EMS crews in NYC do NOT carry paralytics.

9.       Seriously.

10.   EMS crews

11.   in NYC

12.   do NOT carry paralytics.

And finally, don’t forget that these orders for controlled substances will ultimately need a tracking number (MMC-####)! You can offer it to the crew at the time of the order, but often they will just want to call back for it after they secure the tube. That’s fine since you’ll have more time to get patient info and find out how well your medication choices worked!

Hopefully this clears some things up for you all the next time a crew calls for “orders to intubate.” Keep this email and pdf for reference, but also remember that you can use www.nycremsco.org for the latest iterations of the protocols, as well as the hard copy in the protocol binder! It has that fresh book smell!

David Eng

P.S., EMS crews in NYC do NOT carry paralytics.

Can't Miss Dermatology Diagnoses

POTD: Dermatology Part 2 Can’t miss diagnoses

This is a continuation of the previous post.  There is a lot to learn in the field of dermatology.  What are the can’t miss diagnosis that we face in the emergency department?

Red flags of Dermatology

Fever, very young/elderly, toxic-appearing/hypotension, immunocompromised adenopathy, diffuse erythroderma, petechiae/purpura (does the rash blanch with pressure?), nikolsky sign

Nikolsky sign – top layers of skin slip away from lower layers when rubbed

Serious Bullous Diseases

Pemphigus Vulgaris – life threatening (the vulgar one)

Starts in mouth, painful over weeks, non-pruritic, flaccid skin blisters erupt over body, skin breaks easily producing painful erosions (+Nikolsky sign)

Associated with autoimmune disease (myasthenia gravis)

Triggers: captopril, penicillamine, rifampin

Treatment: steroids, IVF, admission to ICU or burn unit, mortality 10-20%

Bullous pemphigoid – not life threatening

Auto-immune disease – mostly in older people, Tense blisters and erosions on skin or mucous membranes

Chronic in older patients, less oral involvement 10-25%, waves and wanes over years, triggered by drugs, UV, radiation therapy

Treat with steroids, consult dermatology

It can be difficult to differentiate bullous pemphigoid and pemphigus vulgaris.  The bullae in pemphigus vulgaris are flaccid with possible nikolsky signs as opposed to the tense bullae of bullous pemphgoid. The disease course of bullous pemphigoid is also more chronic, patient often complaining that similar episodes have been occurring for years.  There is more oral (90%) involvement of pemphigus vulgaris.

Toxic Shock syndrome

Often secondary to tampon use, abscess, nasal packing, surgical wounds, post-partum

Toxic patient with diffuse erythematous rash that affects mucus membrane and conjunctiva

Acute febrile illness and diffuse desquamating erythroderma, rash will fade in 3 days and will have full thickness desquamation

Steph or strep infection that’s Toxin-mediated, as has superantigens that causes uncontrolled T-cell activation and release of cytokines

Diagnosis: fever, hypotension (SBP<90), rash (diffuse, blanching, macular erythroderma), involvement of 3 organ systems

Rx. Supportive care, IVF, broad spectrum abx, clindamycin for toxin foreign body removal, consider burn unit, IVIG can be used as an adjunct to decease reaction to super antigen

Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis

SJS and TEN are part of a spectrum of mucocutaneous reactions often due to medications leading to necrosis and detachment of the epidermis. SJS affects < 10% body surface area. TEN affects > 30% BSA.

Rash: patches often starts centrally, srpeads peripherally sometimes with bullae, can be targetoid, affects mucus membranes including eyes, + nikolsky sign

Triggers: Anticonvulsants, sulmonadmides, NSAIDS, infections

Rx: admit to ICU/burn unit, IVF, supportive care, steroids

Necrotizing Fasciitis 

Necrotizing soft tissue infection

Localized not diffuse that may have bullous component, can appear on any body part but most in lower extremities, abdominal wall, perianal/groin regions (Fournier’s)

Treatment: surgical debridement and broad spectrum abx

Diagnosis: gas on XR, low sodium, elevated Cr, crp, glucose wbc, hemoconcentration, LRINEC score